VP, Physician Review and Market Insights

Become a part of our caring community   Provides executive leadership to Humana.                 The Chief Medical Officer, Utilization Management (UM) will serve as the clinical strategist, operator, and visionary for Humana’s Utilization Management organization. This executive role is responsible for integrating and overseeing all Outpatient and Inpatient based MDs  and RNs and non-clinical support for UM functions in Medicaid and Medicare, with a focus on streamlining processes, ensuring consistent clinical practices, driving trend savings, improving Star Ratings, and enhancing operational efficiency. The CMO, UM will ensure alignment with Humana’s strategic objectives and enterprise operating model. Use your skills to make an impact   Key Responsibilities: •    Set clinical strategy and lead the Utilization Management organization. •    Oversee the integration of medical doctors and registered nurses in UM across Medicaid and Medicare. •    Provide leadership in risk management, grievance and appeals, clinical contracting, vendor management, and UM dental review. •    Ensure the clinician’s perspective is central to organizational decision-making. •    Leverage analytics to inform strategy and performance improvement. •    Sponsor the development of clinical talent and leadership pipeline.   Organizational Scope: The Chief Medical Officer, UM leads a significant functional organization, with direct accountability for human capital and organizational performance.   Direct reports include: VP, Physician Leadership Clinical contracting, physician review, quality improvement, legal MDs Director, Physician Leadership MD vendors, grievance and appeals AVP, UM Nursing UM RNs (transplant, behavioral health, appeals, etc.) Lead Dental Director Dental MD/RN review, bid season benefit review Director, Strategy Advancement Market liaison, provider/facility relationships AVP, UM Administration UM intake, vendor management, administrative support Role Impact: •    Drive the formation, execution, and sustainability of Humana’s Utilization Management strategy. •    Challenge the healthcare status quo to improve quality, Star Ratings, and health outcomes. •    Integrate evidence-based approaches for UM reviewers. •    Support Humana’s commitment to whole-person health and consistent, high-quality outcomes. Candidate Qualifications: •    MD/DO  Current Board Certification Minimum 10 years of combined leadership and/or UM experience. •    Passion for improving Star Ratings, review consistency, and health outcomes. •    Deep knowledge of medical, clinical, and behavioral science underpinning UM. •    Strong interpersonal, leadership, and business acumen. •    Proven ability to drive cross-functional results and champion clinical perspectives. Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.   Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.   Scheduled Weekly Hours 40 Application Deadline: 09-17-2026 About us   About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health –